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Gtk tS ki`kt tl t Ll'ktt Lt Lfi L't l't tt kt l't tt kt l'fi tt kfi L't:tt;tt tt.tt:L,ut�t tfi: <br /> e APPLICITI OR PERMIT r. SdN JOdpUIW LOCAL HEALTH DISiTfCTk: <br /> t: UNDERGROUND TANK t: 1601 8 HAZELTON AVE., STOCKTOY CAL: <br /> t: CLOSURE OR ABANDONMENT t: Telephone (209) 168-3110 t <br /> t L'fi'kt tt L't tt tt tt tl:Lit tlfi Lt tt a a Lt.tl:L•t LIR:ft RLt.Lt:Lfi.tvakv LI:a ti:a a tv <br /> APPLICATION FOR PERMANENT/TEMPORIRY CLOSURE OR ABANDONMENT IN PLACE O8 UNDERGROUND HAZARDOUS SUBSTINCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROTHE APPROVAL DATE. DO NOT WRITE IN III SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> \ RREMOVAL _ TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> EPA SITE I t-LaO n 0 -PROJECT CONTACT 6 TELEPHONE 1 <br /> F FACiLP3Y-NAMB — <br /> �tGlLV�Z6� I I� ---- PHONE I — I-U ,2,�-(q ' --- <br /> -- 77 <br /> C ADDRESS <br /> I <br /> L CROSS STREET �` � p -----_---------------- - -' <br /> 1 <br /> ------- <br /> T OWNER/OPERATOR PHONE I <br /> CFINS <br /> ACTOR NINE <br /> PHONE I <br /> O <br /> ACTOR ADDRESS CI LIC 1 CUSS <br /> T .-----__...__--- - — --RER YORK.COMP.I <br /> C FIRE DISTRICT —--- l PERMIT 1/INSPTR <br /> 0 LABORATORY NAME �I PHONE I <br /> SAMPLING PIRML �j( ,�,,� SAMPLING NETN00 <br /> — INIIIIRNIIIIIgNIIIppRIIIIIIIIIINIIINIIIIIlYXN01111111111iIINNNIIIIpRNIl011NRlpl -------___—_-_. —._— _ LII�IICAL�S <br /> TANK ID I TANK SIZE CHBMICILS STORED CURRENORED PRBVIOUSL <br /> A J9K 39 J --- <br /> - LIST ADDITIONAL TAME INFORMATION AS NEEDED ON SEPARATE FORK <br /> IIIINRpIiIINpRpRDIIIIIIIIWtlIptIININIIppNNIINIIpNNINIIYIINNNIYYIgN IINIIIIIIIRIIDYNIRIIINIRIIIIIIIIIIIIIIIIIIIIIRIIIIIYIIINIIIIIIIIfIINIIIIINIINIIIRNIIgpRIIIIIIIIINNIIIIIIIIIIIIIIgRIIRpRWIRIpYNIIYYIIIIIRNIIINIUINIiINININYIIIIpNYINIIINpMRIIIINIIINIRIIRIIIpYqIINIIpIflIIIIIIqNNlqlllp <br /> P -__ APPROVED _ APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SEB ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME <br /> IIIIIIRKgflNNNIIRKIpINIRYpppNNRlKpppNNXpppNIRlpYgqpppppNpIINIIIININIRINpqINIINppRIqpKNNNDINNRRpIRIRKRYRIKflRRRNIpqqllNqpYlpllplRpplNpNINIIINRRNpNRIIIIRpIflpNRNNpIpNKIYHIpqpYKIpYRII11111KNpNNNIqNpqpIEIRNRRRINYKiRRR <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUWTY ORDINANCES, STATE LAYS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT TO YORKER'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMINCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJBC <br /> TO YORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED_— <br /> -------- ----------- DATE <br /> OFFICE USE ONLY--BF23-04-6-1218—1 --- --- <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSFSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS I COMP IILOC CODE ( DIST CODBI AMOUNT DUE [ AMOUNT RCVD I CKI/CASH I RCYD BY DATE RCVD PERMIT I <br />